Summary: Mr F complained that the care provider failed to provide proper care to his late mother, Mrs J, prior to her death. We found the care provider’s actions caused injustice to Mrs J and her family. The care provider should waive some of the fees to redress this injustice.

The complaint

1. Mr F complains on behalf of his late mother, Mrs J, that Larkhill Hall care home (operated by Ideal Carehomes (Number One) Ltd) failed to provide proper care for her from July to October 2021.
2. Mr F says as a result his mother was left in unsanitary conditions and developed infections, was not supported to eat or drink, and no actions were taken to prevent or minimise her falls risk.

Back to top

The Ombudsman’s role and powers

3. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (Local Government Act 1974, section 26A or 34C)
6. We normally name care homes and other providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
7. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)
8. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

Back to top

How I considered this complaint

9. I spoke to Mr F about his complaint and considered the care provider’s response to my enquiries and the local authority’s safeguarding investigation report.
10. Mr F and the care provider had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

Back to top

What I found

Fundamental Standards of Care

11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall. The standards include:
• Person-centred care (Regulation 9): The service user must have care or treatment that is tailored and meets their needs and preferences. Providers must involve a person acting on the service user’s behalf in the planning of their care and treatment.
• Dignity and respect (Regulation 10): Service users must be treated with dignity and respect and in a caring and compassionate way.
• Safe care and treatment (Regulation 12): Providers must do all that is reasonably practicable to mitigate risks to the service user’s health and safety. The provider must have arrangements to take appropriate action if there is a clinical or medical emergency.
• Food and drink (Regulation 14): Service users must have enough to eat and drink to keep them in good health while they receive care and treatment.
• Premises and equipment (Regulation 15): Providers must make sure that the premises where care and treatment are delivered are clean, suitable for the intended purpose, maintained and where required, appropriately located.
• Complaints (Regulation 16): The provider must have a system in place to handle and respond to complaints.
• Good governance (Regulation 17): Providers must maintain securely an accurate, complete and contemporaneous record in respect of each service user.

Safeguarding

12. A local authority must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk. (Section 42, Care Act 2014)

What happened

13. Mrs J had dementia and health conditions. She required assistance with continence care, was at high risk of falls and had skin breakdown on her legs. Mrs J was living in Larkhill Hall (the Home), operated by Ideal Carehomes (Number One) Ltd (the care provider).
14. In July 2021 Mrs J went into hospital with an infection. She was diagnosed with clostridium difficile (C. diff) infection and other health conditions. She was discharged from hospital on 6 August on end-of-life care. The Home completed a re-admission form but did not review Mrs J’s care plans or complete a preadmission assessment.
15. The Home’s daily notes show that it provided personal and continence care to Mrs J, offered food and drink, and checked for COVID-19 symptoms. District nurses visited to change the dressings on Mrs J’s legs and in pressure areas. Staff applied creams and elevated her legs. There was a sensor and action mat in place due to the risk of falls. Mrs J occasionally refused care and sometimes declined food or drinks. On 12 August it was recorded she had lost 10.6kg so would be weighed weekly but no referral was made to a dietician. Mrs J fell twice, medical advice was sought but she had no visible injuries.
16. On the afternoon of 18 August, Mr J’s niece (Ms Y) found that Mrs J had a soiled top and food on her face from lunch. She complained to the Home manager, who apologised. They discussed Mrs J’s care and agreed that Mrs J required specially adapted cutlery, drinking aids and plates, and more help with eating. Ms Y was concerned about Mrs J sleeping in her chair, her falls, that she was not taken to the toilet and that her pad had not been changed promptly. A referral was made to district nurses for a low bed and Ms Y asked for a crash mat and to move Mrs J’s alarm as she could not reach it. The district nurse found Mrs J’s pressure areas were still very red.
17. Ms Y says after this a winged beaker was used but not a non-spill plate. A low bed was purchased by the Home but it is unclear when this arrived.
18. Mrs J’s personal care plan was updated on 28 August to say she now needed two people to help her due to a deterioration in her mobility. Ms Y says there was an incident where Mrs J became frustrated about not being toileted and threw tea, but this is not recorded in the daily notes. On 7 September she found Mrs J’s room was dirty and smelly. The notes show she had had loose bowel movements but only two pad changes are recorded.
19. Mr F visited on 18 September. He says Mrs J had excrement on her legs, which had wounds, her room smelt of excrement and a dirty pad had been left in the bathroom. Her lunch had not been cut up and there were no staff available to help. The daily notes say staff had tried to clean the carpet “as much as we could”. Mrs J continued to have loose bowel movements and had an unsettled night. The next day the carpet was deep cleaned and the district nurses were called as Mrs J had very sore, broken skin.
20. The district nurse visited on 21 September. She found Mrs J did have an airflow mattress but she was generally unwell, with deep tissue injury to pressure areas and damage to her left leg. The district nurses said Mrs J should be re-positioned every hour and nurses would visit every day. She asked the GP to review Mrs J and raised a safeguarding alert with the local authority. She was concerned that staff had not alerted the Home’s manager or the GP sooner to Mrs J’s deterioration.
21. Mr F and Ms Y met the Home’s manager. They were concerned about Mrs J’s care and that no action had been taken since the complaint on 20 August. Mr F asked for a written plan on how Mrs J’s care would be improved.
22. When he did not receive the written plan, Mr F made a formal written complaint to the care provider on 23 September. He said the GP had only been called about Mrs J’s pressure sores following the district nurse’s intervention and the problems had been going on for weeks. Mr F was also concerned by the number of times Mrs J had fallen and he felt the Home’s staffing was inadequate. Mr F also raised concerns with the CQC and the local authority (the Council). The Council started a safeguarding investigation
23. Mrs J passed away two weeks later.

The care provider’s complaint response and the safeguarding investigation

24. The care provider told Mr F that after 18 August it had purchased a low bed and a chair sensor, deep cleaned Mrs J’s room, provided one to one support with all meals. After 21 September it had increased observations to hourly, updated Mrs J’s care plans and a manager had spoken to Mr F.
25. The care provider replied formally to Mr F’s complaint on 4 October. It apologised for the distress caused to Mrs J and her family. It said:
• A full preadmission assessment was not done when Mrs J came back from hospital.
• There had been no deep clean of the bedroom carpets and soiled cushions were not taken to the laundry in a red bag for cleaning, disposal or replacement. Soiled items had been handled without the use of any PPE. Therefore, the Home had not followed infection control procedures. All staff had now received one to one supervision sessions on infection control
• Mrs J had had nine falls that had not resulted in any injuries. She had not been admitted to hospital due to a fall in the Home but had fallen in hospital. The falls risk assessments were updated and motion sensors were put in place. A low-profile bed had also been purchased.
• Mrs J had lost 10.6kg while in hospital, was weighed weekly and was eating some of her meals but was also refusing meals. Her nutrition and hydration care plan was not reviewed when she returned from hospital, but adapted cutlery, plates and beakers had since been purchased.
• The district nurses had been visiting regularly to dress Mrs J’s legs and pressure areas.
• Ms Y and Mr F’s 20 August complaint was not dealt with appropriately.
• There were some gaps in records and care plans were not updated promptly. A manager was now overseeing Mrs J’s care needs and there would be one to one supervision sessions with staff.
26. The Council closed its safeguarding investigation in November 2021. It found Mr F’s concerns were substantiated and, in addition to the issues listed above, highlighted several areas of concern about the standard of care given to Mrs J. These were:
• Mrs J’s skin integrity was not checked frequently enough.
• The recording of falls was inconsistent and it was unclear why medical advice was sought on some occasions but not others.
• Ten district nurse visits had not been recorded.
• Mrs J regularly refused food or ate very little and on occasion declined fluids but there were inconsistent records about whether she was on a fortified diet and whether she was offered alternatives.
• Between 2 June and 23 September 2021 Mrs J lost 17.45 kg in weight but no malnutrition risk score was completed and there had been no referral to the dietician or GP. The care provider said this was because it was not deemed appropriate as Mrs J was on end-of-life care. It also noted that C. diff and being at end of life could cause weight loss.
• The quality and content of the care plans was scanty and it was unclear when actions were implemented as record keeping was inconsistent.
27. In response to the safeguarding investigation the Home said a management plan had been drawn up and it would carry out an internal investigation as the initial complaint had not been investigated. The Home’s manager had left and staff would be re-trained in infection control and dignity.
28. The safeguarding report made a number of recommendations to the care provider to improve its practices, for example in record keeping, care planning, monitoring skin integrity and reporting concerns to medical staff.

My findings

29. The Council carried out a full and detailed safeguarding investigation into the concerns raised by Mr F. It found the standard of care to Mrs J in September 2021 was “less than satisfactory” and that the safeguarding concerns were substantiated.
30. I find there were failings in the care provided to Mrs J. In particular in relation to skin integrity, infection control and nutrition. I find that appropriate action was taken in response to Mrs J’s falls and risk of falls but concerns were not escalated quickly enough about her skin breakdown and weight loss. In addition, there was poor record keeping, care plans were not updated and Ms Y and Mr F’s initial complaint was not formally responded to.
31. These failures are potential breaches of the fundamental standards in relation to person centred care, dignity, safe care, food and drink, premises, complaint handling and record keeping (Regulations 9, 10, 12, 14, 15, 16 and 17) so I will share my final decision statement with the CQC.
32. I cannot say that Mrs J’s death was caused by poor care or identify the source of her infections. However, she was caused distress and injustice by the actions of the care provider. Mr F and the family also suffered distress as they witnessed Mrs J’s poor care at a particularly difficult time when she was at the end of her life. Mr F and Ms Y were also caused time and trouble by the failure to formally respond to the August 2021 complaint.
33. On the evidence seen, I am satisfied Mrs J did not receive the expected standard of care at the Home from 6 August 2021 to her death.
34. The Ombudsman’s guidance on remedies says that when we find evidence that the care someone received was so poor the fundamental standards may not have been met, a refund or waiving of some of the fees is appropriate. This is because we consider the person did not receive the service either at all or to an acceptable standard. Sadly, Mrs J has now died but we are able to recommend repayment of a loss to a deceased person’s estate.

Back to top

Recommended action

35. Within a month of my final decision, the care provider should apologise to Mr F and refund or waive 50% of the fees owed for Mrs J’s stay from 6 August to 8 October 2021.

Back to top

Final decision

36. There was fault causing injustice. The care provider should take the recommended action to remedy that injustice. I have completed my investigation.

Back to top

Investigator's decision on behalf of the Ombudsman